Verteporfin photodynamic therapy for neovascular age-related ...
Verteporfin photodynamic therapy for neovascular age-related ... Verteporfin photodynamic therapy for neovascular age-related ...
184 Appendix 2RESOURCE USE QUESTIONNAIRE (administered)PATIENT SURNAME:_______________ DATE OF BIRTH:___________HOSPITAL NO:_____________________ DATE OF VISIT: ___________Interviewer to say:“We are conducting a study to assess the benefits of a new treatment for maculardegeneration, called photodynamic therapy. Part of the study involves finding out aboutthe costs of the illness to you. This questionnaire aims to find out about the costs involved inhaving macular degeneration. All the answers given will be kept confidential and only usedfor research purposes. They will not affect your care in any way”.TREATMENT AT AND VISITS TO THE HOSPITALQ1Did you experience any serious complications when you last had eitherangiography or photodynamic therapy treatment that resulted in:Your treatment being stopped? yes noBeing admitted to hospital? yes noQ2During the last three months, have you had to make any extra visits toyour eye consultant?yesnoQ3a) During the past three months, have you telephoned the Eye Hospitalhelp-line, or another member of staff at the Eye Hospital, because of youreye condition?b) If yes, how often? (Tick boxes to indicate member of staff telephoned)Help-lineOphthalmologistOptometristOther staff(if other, who?)yesCall 1 Call 2 Call 3 Call 4 Call 5 Call 6no
DOI: 10.3310/hta16060Health Technology Assessment 2012; Vol. 16: No. 6185Q4a) During the past three months, have you visited the Eye Hospital for alow vision appointment (vision rehabilitation, appointment to see whethermagnifiers can help your vision)?b) If yes, how many times?yesnoVisit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6Low visionappointmentPLEASE COMPLETE QUESTIONS 5-7, EVEN IF ANSWERED ‘NO’TO Q4Q5 When you visit the Eye Hospital, does someone usually come withyou, for example your husband/wife, a relative or a friend?yesnoQ6When you visit the Eye Hospital, how long does your visit take intotal (including time travelling to and from the Eye Hospital andwaiting time to see the consultant or other members of staff in thehospital)(hrs/mins)Q7When you visit the Eye Hospital, how much does it cost you andanyone who comes with you?*Interviewer comments about mode of travel and availability ofconcessions, e.g. bus pass:(enter total cost, £)* Note: if the patient comes by car and is unaware of the cost, ask him/her what thetotal miles taken for the visit was (to and from the clinic)VISITS TO OR FROM GENERAL PRACTICEQ8a) During the past three months, have you visited your GP, or other staff inthe GP surgery, because of your eye condition?b) If yes, how often? (Tick boxes to indicate staff seen on each visit.)yes noIf no, goto Q12Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6GPPractice nurseOther staff(if other, who?)Q9 When you visit your GP surgery, does someone usually come with yes no© Queen’s Printer and Controller of HMSO 2012. This work was produced by Reeves et al. under the terms of a commissioning contract issued by theSecretary of State for Health.
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DOI: 10.3310/hta16060Health Technology Assessment 2012; Vol. 16: No. 6185Q4a) During the past three months, have you visited the Eye Hospital <strong>for</strong> alow vision appointment (vision rehabilitation, appointment to see whethermagnifiers can help your vision)?b) If yes, how many times?yesnoVisit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6Low visionappointmentPLEASE COMPLETE QUESTIONS 5-7, EVEN IF ANSWERED ‘NO’TO Q4Q5 When you visit the Eye Hospital, does someone usually come withyou, <strong>for</strong> example your husband/wife, a relative or a friend?yesnoQ6When you visit the Eye Hospital, how long does your visit take intotal (including time travelling to and from the Eye Hospital andwaiting time to see the consultant or other members of staff in thehospital)(hrs/mins)Q7When you visit the Eye Hospital, how much does it cost you andanyone who comes with you?*Interviewer comments about mode of travel and availability ofconcessions, e.g. bus pass:(enter total cost, £)* Note: if the patient comes by car and is unaware of the cost, ask him/her what thetotal miles taken <strong>for</strong> the visit was (to and from the clinic)VISITS TO OR FROM GENERAL PRACTICEQ8a) During the past three months, have you visited your GP, or other staff inthe GP surgery, because of your eye condition?b) If yes, how often? (Tick boxes to indicate staff seen on each visit.)yes noIf no, goto Q12Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6GPPractice nurseOther staff(if other, who?)Q9 When you visit your GP surgery, does someone usually come with yes no© Queen’s Printer and Controller of HMSO 2012. This work was produced by Reeves et al. under the terms of a commissioning contract issued by theSecretary of State <strong>for</strong> Health.
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